Musings in the life of an internist, cardiologist and cardiac electrophysiologist.

Thursday, August 16, 2012

Granny and Me

Ugh. It’s impossible to watch the news these days. Whether you’re conservative, liberal, independent or non-committed, it’s impossible to avoid the political bickering these days as the U.S. Presidential campaign enters its final countdown. As a physician, seeing the video of Granny being pushed off a cliff is about all I can handle.

Seriously?

No politician I know has to deal directly with Granny, but I do. I have to look her in the eye. I have to talk to her. I have to be there when she comes in with a heart that’s not beating. I have to look at her struggling to breathe. I have to decide, based on the available information like her current and past medical history, social situation, family member concerns, prior surgical history, medications, lab tests, and a myriad of other variables whether to given granny a pacemaker or not.

Not you, Mr. Politician. Not Obamacare. Not my hospital. Not the insurance company. Not Big Data.

Me.

And for the moment, I’ve got granny’s back. No matter what, if she wants and needs a pacemaker, she'll get it.

But everything that is being proposed to save costs in health care these days threatens my ability to make the right choice for granny.

For Democrats, they want a 15-member non-elected panel that might set a limit on certain aspects of when I can give granny a pacemaker despite what she and I might think. For Republicans, they want to allow insurance companys and their Big Data (or a pre-programmed supercomputer called “Watson”) to tell be when I can or cannot give Granny a pacemaker despite what we might think. And both political parties want to do this in the face of a tort system that hasn't had to change at all to account for these financially-imposed ultimatims for care.

In addition, both political parties seem to be aligning behind ideas that cut payments for what I do directly, and somehow pay me for my "outcomes" of care via “bundles” (or some other concocted payment scheme) that defines how to distribute the bundle to the various “stakeholders” in granny’s care, including me. Even more telling, we see another new iniative currently being rolled out: if Granny gets an infection despite perfectly acceptable care and comes back for follow-up management, guess who won’t get paid for her ongoing care after January 1, 2013? Neither my hospital nor me.

Talk about shifting risk!

So the risk of Granny’s pacemaker care in our current capitated ACO world is shifting ever-so-quickly from a company who is in the business of taking risk (insurers), to hospitals and me who are not in the business of taking risk. I am in the business of caring for patients and expecting I’ll get paid for that care. I do not have a big, fat, holding pen of reserves that people pay in to for assuming their health care risk like an insurance company. I just have a personal checking and savings account. (No wonder hedge funds are lining up behind insurance companies - it's a win/win for their profits!)

This trend is only getting worse. In a piece entitled “Tackling Rising Health Care Costs in Massachusetts” that appeared yesterday in the online version of the New England Journal of Medicine, we find that the near-universal health care law in Massachusetts (upon which our current health care law is modeled and was sold as cost-cutting) has the "highest personal health care spending per capita of any state." As a result, we also learn of a new law that was just passed to counteract this fact that contains measures that further shifts the cost risk further from insurers to the hospitals and doctors. In fact, as one former Boston hospital CEO has pointed out:

Even if you believe that capitated contracts are the best thing that could happen in health care, you should not and cannot believe that the transfer of risk inherent in such contracts should go unrecognized. The state's failure to account for this gift to the insurance company represents an example of incomplete policy-making.

But doctors in Massachusetts have recognized the problem. The legislature there forgot to consider what doctors are actually doing in Massachusetts:

9 comments:

So let's say Granny gets referred to me with an infected biventricular ICD pocket after a generator change done a month earlier. The leads are 10 years old, and she's pacer dependent. She's got a mechanical mitral valve.

She's gonna be really tough to take care of. The record review, decision management and counseling will be challenging and time consuming. The procedure will generate enough stress to take a few days off the end of my life. She'll occupy a bed on my service for about a week while I we get her better and re-implant her next device. She'll be at risk for reinfection and require a lot of post op attention. Taking care of her will be one of the toughest things I do this year.

If something goes wrong, I might get sued. Maybe she'll just name me in a suit against the doc that did the previous generator replacement.

Per the new CMS rules, it looks like I won't get paid a dime for any of this. The hospital won't either.

This Granny isn't my patient yet. I didn't do her procedure. We haven't even met. Her surgery is not an emergency and there are others who can do it.

It's a mess isn't it? But I'm proud of you. I note that you criticized Democrats AND Republicans. But you'll really get my praise when you talk about the nation's largest hospital chain: HCA. It's VERY profitable (even after having to pay almost a billion dollar fine to Medicare for fraud. Also noted, the fraud didn't stop its president, Rick Scott, becoming gov. of Florida). Some of the current profits have been generated by unnecessary heart surgeries.

I repeat, it's a mess, isn't it.

We are attacked on all fronts: we live too long, medical technology is too innovative and therefore too expensive, there are too many people without insurance and without jobs (maybe there are just too many people), there are not enough doctors and perhaps not enough med schools, med schools are too expensive, people don't have end of life plans, too many people find attorneys who will file silly lawsuits, but doctors and hospitals do make terrible mistakes, etc., etc., etc.

You're a good guy but I feel the emotional side of you longs for the REALLY old days when the doctor patient relationship was terribly close and if the guy lived he owed you $5 and a chicken.

Just before you left for vacation there was a doc who railed at Obama for the destruction of that cherished bond between doctor and patient. But the doc balked at having to know the cost of the script he was about to write. Does he have any idea how much a script can cost? I was floored when I got one filled and it cost $125! Does he know how many scripts are never filled because the patient has to feed his kids and get gas for the car?

Nearly everyone is insured in MA and still the cost keeps growing. So? What do you want to do? Denial of care for those over 80? Denial of care for births under 30 weeks? Denial of care for 2nd occurance of cancer? Or should we just give one big "voucher" to MA, say $700 million per year, and nothing else can be spent. Or should we just do it the good old fashioned free market way: no insurance, no money, no care. None of this Emergency Room escape clause. Or should we close all the assisted living facilities to all those who can't pay $7,000 per month?

If you care going to complain about the ever growing costs, I think you are obliged to give me your solution or at least specifically acknowlege that there are losers besides the doctors and the hospitals.

This is a short analogy to what is happening in the market for medical services. What does a market for wheat have to do with healthcare? It is easier to understand.

In short. Say the government steps in to take and redistribute wheat to the poor, but without paying the market price. Some wheat production is suppressed, and the price goes up. The cry goes out from even more people who now cannot afford wheat. The government reallocates more of it. The price goes up again. Then, the government gets serious.

This is a longer, readable analogy and explanation of Medicare economics.

Say that tomatoes were declared vital to life and made available free through the Medicare National Tomato Bank. This is the healthcare market translated to the tomato market.

Medicare/Medicaid spending currently buys half of healthcare. Government underpays, and doctors and hospitals stay in business by shifting the unpaid costs onto the insured patients, the ones who can pay and don't see the bills. The cost of insurance goes up. People cry out that they can't afford it. Then, the government gets serious.

You are a familar commentor. I believe you are not interested in distributing wheat to the poor and would not be terribly surprised to hear you say "let them eat cake". We probably don't have much to say to one another.

The good doctor, on the other hand, does have a very sound heart, and that is why I continue to read him.

You are anonymous. If you had any faith in your own judgement, you would declare your identity and would present facts rather than supposition about what you "think" I am interested in, and what you would or would not be surprised to hear me say. Your analytic achievement seems to top out at name calling.

One topic is how to care for the poor. But, that is not what is afflicting healthcare. The government is not paying reasonable rates to deliver scarce medical resources efficiently to the needy. The government has decided to shift the burden onto the doctors, hospitals, and insured patients. This is raising prices, supressing supply, putting emergency departments and hospitals out of business, discouraging doctors, and imposing immense administrative costs.

The government cannot long run this sort of charity through oppressive regulation, hiding the true costs from taxpayers. If you care about the poor, then you don't want to ruin the system (the paid cooperation of skilled participants) which is supposed to do the caring.

Anony - ... although I seek to beat him bloody for his political views.

Look, Granny and I have enough problems without beatings, too!

:)

Seriously, both you and Mr. Garland have some valid points. I appreciate the (relatively) civil but forthright tone. But we must stick to topic.

And the topic in this post is Granny and me.

You see, Anony, it's not just about me.

Granny is a figurative Granny, to be sure. In reality some grannys are wealthy, many more are not. Granny is scared. Granny probably has lots of complicated health problems, not just one that follows a “guideline.” Granny needs competent health care. So granny needs a real doctor. (Sure, nurse practitioners are okay for the access, the little stuff, but the complicated stuff? She’ll likely need a doctor.)

As Mr. Garland (and I, hopefully) points out, our system is systematically beating up doctors and asking them to take on considerable risk that they are not set up to handle. And no matter which party we're talking about (yep, EITHER party), doctors are waking up to this reality now that they're seeing how our new health care environment is REALLY affecting their relationship with Granny and (via their personal checking accounts) their own families.

Look, I bet there are lots of docs who would (TODAY) take $5 and a chicken for the care they provide a Medicaid patient in our state. Why? Because we haven't seen a penny from our state for payment of our services for so long that even $5 for our services looks better than nothing. And we want to put more and more people on this system? The endemic problem of political self-serving crosses political lines and leaves doctors AND patients like Granny yearning for the "old days" when people that stood between them were not needed. It would certainly beat what is going on now.

Politicians, no matter how well-intentioned, should not be in the business of medicine.

So what is likely to happen? What I see evolving (at least in the short term) is two-tiered medicine. (Politicians, insurance executives, and union members have their own sweet deals - so maybe it will evolve (sadly) to a three-tiered system) Right now, this seems inevitable given the looming doctor shortage.

Oh sure, to quell discontent amongst the rank and file Americans due to the doctor shortage, politicians will probably open gates for foreign medical doctors irrespective of the foot-stomping by the AMA. But this will not reassure the remaining physician force that their credentials are valued nor correct the ever-increasing cost of health care that the patient must endure in our current system since our insurers (INCLUDING a single government insurer) and admin overhead will still work to assure their OWN security and profit before Granny gets her covertly rationed care.

I certainly agree with you: health care is a mess. No one knows what it costs because no one wants Granny and me to know. But I remain optimistic that a solution that eventually removes much of the costly administrative, legal, and third-party overhead for health care that returns to a pact between doctor and patient ALONE can be found. Perhaps it will involve information technology and patient engagement in their care. Maybe new financial incentives for savings and investment for Granny’s own care that began at her birth. Maybe a transparent and understandable insurance market will develop. Maybe something else. Who knows? But it will NOT be the current envisioned system – no matter how it’s being painted. That system is on a fiscal bridge to hell.

One thing's for certain. This health care story isn't over. Not by a long shot.

We are attacked on all fronts: we live too long, medical technology is too innovative and therefore too expensive, there are too many people without insurance and without jobs (maybe there are just too many people), there are not enough doctors and perhaps not enough med schools, med schools are too expensive, people don't have end of life plans, too many people find attorneys who will file silly lawsuits, but doctors and hospitals do make terrible mistakes, etc., etc., etc.*****************************

I'm not sure what health care system will work so that it's just between you and Granny when Granny is a stand-in for 310 million Americans. But I suggest that the way that was done in whatever golden period you chose will not work in today's world unless you are willing to discard tons of Americans and tons of technology. No more keeping heart patients alive until 90, premies less than a pound, and organ transplants.So let's remember the good old days... Are you content to allow insurance companies to deny insurance for pre-existing conditions? How about their practice of rescission? Does fee for service work? Is ER care the way to go? Should the government subsidize any part of health care or do you agree with Mr. Garland that that just mucks up the market? I think he all for free markets. Swell. Let's get rid of NIH and no tax breaks for R&D or "non-profit" hospitals. (Boy, wouldn't I love to see Medtronics tax returns!) Administrative overhead? For sure. Allow me to remind you of HCA. I've seen the waterfall walls. SOMEBODY is making a lot of money.

You write: "Should the government subsidize any part of health care, or do you agree with Mr. Garland that that just mucks up the market?"

Government subsidies to consumers of healthcare increase the resources available to produce healthcare. They are also public and accountable costs which get the attention of taxpayers.

Subsidies are not mucking up healthcare. Government is setting prices which are below the reasonable costs of the product.

Their are limits to the charity services which government can force doctors and others to provide. Providers move inevitably to either provide lowered services matching what they are paid, or to find other work which pays better.

Government cannot subsidize people at half the market rate and expect those people to get full services.

In short, government is bullying people to provide healthcare. That is killing healthcare. Government claims that is is doing this with charitable intent, but that doesn't matter to the outcome.

About Me

Westby G. Fisher, MD, FACC is a board certified internist, cardiologist, and cardiac electrophysiologist (doctor specializing in heart rhythm disorders) practicing at NorthShore University HealthSystem in Evanston, IL, USA and is a Clinical Associate Professor of Medicine at University of Chicago's Pritzker School of Medicine. He entered the blog-o-sphere in November, 2005.
DISCLAIMER: The opinions expressed in this blog are strictly the those of the author(s) and should not be construed as the opinion(s) or policy(ies) of NorthShore University HealthSystem, nor recommendations for your care or anyone else's. Please seek professional guidance instead.